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The New ICRU/GEC‐ESTRO Report in Clinical Practice
Christian Kirisits, MSc, PhD; Richard Pötter, MDMedical University of Vienna, Vienna, Austria
On behalf of the Committee: B. Erickson, C. Haie‐Meder, E. van Limbergen, J. Lindegaard
J. Rownd, K. Tanderup, B. Thomadsen
Disclosures
Christian Kirisits, MSc, PhD, was a consultant to Nucletron, an Elekta Company.
Richard Pötter, MD, does not have any financial relationships or products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
The Medical University of Vienna receives financial and equipment support for training and research activities from Nucletron, an Elekta Company and Varian Medical.
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Table of Contents
• 1 ‐ INTRODUCTION
• 2 ‐ PREVENTION, DIAGNOSIS, PROGNOSIS, TREATMENT AND OUTCOME
• 3 ‐ BRACHYTHERAPY TECHNIQUES AND SYSTEMS
• 4 ‐ BRACHYTHERAPY IMAGING FOR TREATMENT PLANNING
• 5 ‐ TUMOR AND TARGET VOLUMES AND ADAPTIVE RADIOTHERAPY
• 6 ‐ ORGANS AT RISK AND MORBIDITY‐RELATED CONCEPTS AND VOLUMES
• 7 ‐ RADIOBIOLOGICAL CONSIDERATIONS
• 8 ‐ DOSE AND VOLUME PARAMETERS FOR PRESCRIBING, RECORDING, AND REPORTING OF BRACHYTHERAPY ALONE AND COMBINED WITH EXTERNAL BEAM RADIOTHERAPY
• 9 ‐ 3D VOLUMETRIC DOSE ASSESSMENT
• 10 ‐ RADIOGRAPHIC DOSE ASSESMENT
• 11 ‐ SOURCES AND DOSE CALCULATION
• 12 ‐ TREATMENT PLANNING
• 13 ‐ SUMMARY OF THE RECOMMENDATIONS
• APPENDIX – EXAMPLES, SPREADSHEETS, DRAWINGS
Concepts and terminology for prescribing
Level Concept
Reporting and recording in a level concept:
•Level 1 –Minimum standard for reporting
•Level 2 – Advanced standard for reporting
•Level 3 – Research‐oriented reporting
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From Planning Aims to Prescription
Traditional concepts:
“when prescribing to a target the prescription“when prescribing to a target, the prescription
dose is the planned dose to cover this target as
completely as possible.”
or
prescription to a 100% isodose which is “to
cover” the target volume
Chapter 8
Need for Common Terminology According to ICRU Reports on Proton Treatment and IMRT
• Planning aim dose
– Set of dose and dose/volume constraints for a t t ttreatment
• Prescribed dose
– Finally accepted treatment plan (which is assumed to be delivered to an individual patient)
• Delivered dose
– Actually delivered dose to the individual patient
Chapter 8
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Need for Common Terminology According to ICRU Reports on Proton Treatment and IMRT
Example:
Previously: 4x7 Gy ~ 84 Gy EQD2 prescribed, D90 was mean 93 Gy
Planning aim was to deliver 4 x 7 Gy ~ 84 Gy, D2cm³ for rectum, sigmoid <70 Gy EQD2, bladder <90 Gy EQD2
Prescribed dose was mean 93 Gy ± 13 Gy (1SD) EQD2 to D90 HR CTV
Delivered dose? Depending on variations and uncertainties – on average no systematic deviation from prescribed dose
Various Patterns of Tumor Response‐Adapted CTV
Chapter 5
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Various Patterns of Tumor Response‐Adapted CTV
Chapter 5
Level 1 –Minimum Standard for Reporting
• Comprehensive clinical gynecologic examination
• Volumetric imaging (MRI, CT, US, PET CT) at time of diagnosis and BT
FIGO/TNM t• FIGO/TNM stage
• Baseline morbidity and QoL assessment
• Schematic 3D documentation on a clinical diagram indicating dimensions and volumes for:
– GTVinit ( GTV at diagnosis)
– GTVres (GTV at brachytherapy)
– CTVHR (GTVres (plus residual pathologic tissue plus whole cervix)
– (CTVIR: GTVinit and CTVHR plus safety margin if used for prescription)
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Example – Clinical Drawings
h
t4.8 cm
3.5 cm
4.3 cm
4.8 cm
Example
Diagnosis BT1+2 BT3+4
Clinical dimensions GTV w * t (mm) 60 *40 ‐ ‐
Dimensions and volumes of GTVs and CTVs at diagnosis and at brachytherapy
( )
MRI dimensions GTVw * t * h (mm)
55*40*45 35*35*43 35*35*43
MRI volume GTV (cm3) 52 33 33
Clinical dimensions CTVHR w * t (mm) ‐ 50*40 50*40
MRI dimensions CTVHR
w * t * h (mm)
‐ 48*35*43 46*32*41
CTVHR (cm3) ‐ 43 43HR ( )
CTVIR (cm3) ‐ 88 88
Left parametrium proximal proximal proximal
Right parametrium proximal proximal proximal
Vagina upper third not involved not involved
Bladder not involved not involved not involved
Rectum not involved not involved not involved
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Level 1 –Minimum Standard for Reporting
Dose reporting:
• TRAK
• Point A dose
• Recto‐vaginal reference point dose
• D0.1cm³,D2cm³ for bladder, rectum
or
Bladder reference point for radiographs
Chapter 8 and Chapter 10
Point A
0.5 cm0.5 cm
2cm
2cm
2cm
2cm
0.5 cm 0.5 cm
Pt A Pt A
2cm
Pt A
AxialCoronal
Sagittal
Chapter 10
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Point A
0.5 cm0.5 cm
2cm
2cm 2cm
2cm
0.5 cm 0.5 cm
Pt A Pt A
2cm
Pt A
Axial Coronal Sagittal
Chapter 10
OAR Concept and Related Volumes
Chapter 6
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Level 2 – Advanced Standard for Reporting
All that is reported in level 1 plus:
3D delineation of volumes (on volumetric images with applicator and on clinical diagrams):and on clinical diagrams):
• GTVres• CTV HR• (CTV IR if used for prescription)
• With maximum width, height, thickness and with volume
Chapter 5
Level 2 – Advanced Standard for Reporting
All that is reported in level 1 plus:
Dose reporting for defined volumes:
• D98, D90, D50 for CTVHR
• (D98, D90 for CTVIR if used for prescription)
• D98 for GTVres• D98 for pathological lymph nodes
Chapter 8
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Level 2 – Advanced Standard for Reporting
All that is reported in level 1 plus:
Dose reporting OARs:
• Bladder reference point dose• Bladder reference point dose
• D0.1cm³,D2cm³ for sigmoid*
• D2cm³ bowel (if fixed)*
• Intermediate and low dose parameters in bladder, rectum, sigmoid, bowel (e.g. V25Gy, V35Gy, V45Gy or D98%, D50%, D2%)
• Vaginal point doses at level of sources (lateral at 5 mm)**
• Lower and mid vagina doses (PIBS, PIBS ±2cm)**
Chapter 8
Vaginal Reference Points
Chapter 8
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DVH for OAR
Chapter 8
45 Gy Whole Pelvis EBRT plus 4 Fractions of HDR Brachytherapy (Total Target Dose: 85 Gy EQD2)
Chapter 8
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45 Gy Whole Pelvis EBRT plus 15 Gy EBRT Tumor Boost plus 2 Fractions of HDR Brachytherapy (Total Target Dose: 85 Gy EQD2)
Chapter 8
Example
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Example
Planning aim Prescribed dose
CTVHR D90 EQD210 ≥85 Gy 92.3 Gy
Bladder D2cm³ EQD23 ≤90 Gy 80.6 Gy
Rectum D2cm³ EQD23 ≤70 Gy 64.3 Gy
Sigmoid D2cm³ EQD23 ≤75 Gy 51.7 Gy
Example1st application 2nd application Total dose
BT1 BT2 BT3 BT4 EBRT+BT
(Gy) (Gy) (Gy) (Gy)(Gy in EQD2))
Point A right x* x* x* x* x*
left 7.0 7.0 7.8 7.8 87.2
Pelvic Wall Point right 1.1 1.1 1.0 1.0 48.2
left 1.0 1.0 1.1 1.1 48.2
Bladder ICRU point 2.8 2.8 5.5 5.5 68.4
Recto Vaginal ICRU point 2 4 2 4 3 5 3 5 57 5Recto‐Vaginal ICRU point 2.4 2.4 3.5 3.5 57.5
Vagina 5 mm right 7.5 7.5 7.6 7.6 106.9
left 7.3 7.3 7.2 7.2 102.7
PIBS** +2 cm 5.9 5.9 6.3 6.3 88.8
0 cm 2.6 2.6 2.4 2.4 53.4
‐ 2 cm 0.6 0.6 0.7 0.7 7.3
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Example
1st application 2nd application Total dose
BT1 BT2 BT3 BT4 EBRT+BT
(Gy) (Gy) (Gy) (Gy) (Gy in EQD2)
GTVres D98 10.1 10.1 10.7 10.7 115.0
D90 11.9 11.9 12.4 12.4 134.0
CTVHR D98 6.5 6.5 6.7 6.7 80.8
D90 7.9 7.9 8.1 8.1 92.3
D50 11.7 11.7 11.5 11.5 127.8
CTVIR D98 3.7 3.7 4.1 4.1 62.3
D90 4.6 4.6 5.3 5.3 69.0
D50 8.5 8.5 8.7 8.7 97.6
Bladder D0.1cm3 7.2 7.2 7.2 7.2 102.0
D2cm3 5.6 5.6 5.4 5.4 80.6
Rectum D0.1cm3 4.8 4.8 5.0 5.0 74.2
D2cm3 3.8 3.8 3.9 3.9 64.3
Sigmoid D0.1cm3 1.9 1.9 4.4 4.4 59.9
D2cm3 1.5 1.5 2.6 2.6 51.7
Dose Estimation in Case of Radiographs
Chapter 10
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Conclusion
Concepts and terminology for prescribing,recording, and reporting
In a level concept:
• Level 1 –Minimum standard for reporting
• Level 2 – Advanced standard for reporting
Thanks for your attention!
f p g
• Level 3 – Research oriented reporting